Psychological Assessment of Patients with Behavioral Symptoms



Psychological Assessment of Patients with Behavioral Symptoms





The evaluation of patients who show abnormal behavior typically occurs in the context of the clinical interview (see Chapter 24). The psychiatric history and structured instruments, such as the mental status examination (MSE) and Beck Depression Inventory (BDI), are also used in the evaluation of such patients.

Evaluation instruments can be administered to an individual or to a group of individuals at one time. Individually administered tests allow careful observation and evaluation of that person. Tests given to a group of people simultaneously have the advantages of efficient administration, grading, and statistical analysis. Tests commonly used in the psychological evaluation of patients fall into three main categories: intelligence, achievement, and personality/psychopathology (Table 10-1).


• PSYCHIATRIC EVALUATION


The psychiatric history

A patient’s psychiatric history is taken as part of the medical history. Although both histories focus on gathering factual information to define the chief complaint and determine the background of the current illness, the psychiatric history also investigates the patient’s personality characteristics, relationships with others, and sources of stress. Aspects of the psychiatric history are summarized in Table 10-2.


The MSE and related instruments

The MSE is a comprehensive survey used to evaluate an individual’s current state of mental functioning. The MSE assesses a variety of characteristics, including general presentation (appearance, behavior, attitude toward the examiner, and level of consciousness); cognition (orientation, memory, attention and concentration, cognitive ability, and speech); emotional state (mood and affect); thought (form or process, content); perception; judgment and insight; and reliability and impulse control (Table 10-3). Terms used to describe psychophysiologic symptoms and mood in patients with psychiatric illness are listed in Table 10-4.


Rating scales for depression

The BDI-II is a commonly used self-rating scale containing 21 items (Table 10-5). Each item on the BDI-II has four possible answers scored from 0 to 3 (lowest to highest level of depression); 63 is the highest total score. For example, for item number 5, guilt, the patient must choose one of the following four choices:



  • I do not feel particularly guilty = 0 points


  • I feel bad or unworthy a good part of the time = 1 point


  • I feel quite guilty = 2 points


  • I feel as though I am very bad or worthless = 3 points

Because the BDI-II asks about the presence of depression directly and is easy to administer, it is particularly useful in primary care.

Other rating scales of depression include the Zung, Hamilton, and Raskin scales. Using the Zung Self-Rating Depression Scale, the patient rates herself with respect to symptom severity. With the Hamilton Rating Scale for Depression (HAM-D), the examiner interviews and rates the patient from 0 to 4 on characteristics such as work and activities, anxiety and somatic symptoms, and feelings of guilt, helplessness, hopelessness, and worthlessness. On the Raskin Depression Scale, the patient is rated using his or her own verbal report and on displayed behavior and secondary symptoms.









table 10.1 COMMONLY USED INTELLIGENCE, ACHIEVEMENT, ATTENTION AND CONCENTRATION, AND PERSONALITY/PSYCHOPATHOLOGY TESTS


















TYPE OF TEST

SPECIFIC TEST


Intelligence

Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV)


Wechsler Intelligence Scale for Children (WISC)


Wechsler Preschool and Primary Scale of Intelligence (WPPSI)


Stanford-Binet Intelligence Scale


Achievement

Scholastic Aptitude Test (SAT)


Medical College Admissions Test (MCAT)


United States Medical Licensing Examination (USMLE)


Wide-Range Achievement Test (WRAT)


California, Iowa, Stanford, and Peabody Achievement Tests


Woodcock-Johnson Psychological and Educational Battery


Attention and concentration

Wisconsin card sort


Digit span (component of the WAIS and Mini-Mental State Exams)


Personality and psychopathology

Minnesota Multiphasic Personality Inventory (MMPI)


Rorschach Test


Sentence Completion Test (SCT)


Thematic Apperception Test (TAT)


Mental Status Examination (MSE)


Beck Depression Inventory-II (BDI-II)


Zung Self-Rating Depression Scale


Hamilton Rating Scale for Depression (HAM-D)


Raskin Depression Scale









table 10.2 AREAS ADDRESSED IN THE PSYCHIATRIC HISTORY



















EARLY CHILDHOOD (0-3 YEARS)

CHILDHOOD (3-11 YEARS)

ADOLESCENCE (11-20 YEARS) AND ADULTHOOD (>20 YEARS)


Background




  • Normal pregnancy and delivery?



  • Wanted child?



  • Feeding, sleep, and toilet training?



  • Timely development of motor and social skills?



  • Caretakers other than mother?


  • School history and skill development?



  • Learning disabilities?



  • Punishment methods used in the home?



  • Response to first separation from mother?


  • Employment history?



  • Legal history?



  • Psychiatric history of family members?



  • Military service?



  • Level of education achieved?



  • Religious activities?



  • Current living situation?


Personal characteristics




  • Parental and sibling relationships?



  • Personality (e.g., shy or outgoing, active or passive)?



  • Temperament (e.g., easy, difficult, slow to warm up)?


  • Peer relationships (e.g., follower,leader, popular)?



  • Personality (e.g., assertive, anxious)?



  • Presence of unrealistic fears?



  • Cruelty to animals, bed wetting?


  • Emotional problems?



  • Drug and alcohol use?



  • Role models?



  • Social relationships?



  • Sexuality?



• INTELLIGENCE


Intelligence versus achievement

Intelligence and achievement, although related, are different entities. Achievement is a culture-specificmeasure of knowledge and skills acquired from education and experience. In contrast, intelligence is a measure of an individual’s innate potential for learning. Intelligence is quantified by the ability to reason; to think logically and come to

a conclusion; to understand abstract concepts; to assimilate, recall, analyze, and organize information; and to meet the special needs of new situations.








table 10.3 THE MENTAL STATUS EXAMINATION

























































































CATEGORY

CHARACTERISTIC

EXAMPLE INDICATING NEED FOR FURTHER EVALUATION


Presentation


Appearance

Posture


Grooming


Appearance for age


Clothing

Has a hunched-over posture while standing


Is unshaven


Appears older than his chronological age


Is wearing a heavy coat on a hot day


Behavior

Mannerisms


Psychomotor behavior


Tics

Shows unusual facial expressions or hand movements


Seems physically speeded up (agitated) or slowed down (retarded)


Uses repetitive, nonproductive movements


Attitude toward the examiner

Cooperative


Seductive


Hostile


Defensive

Is not helpful


Behaves in a sexually provocative fashion


Seems angry


Seems to take remarks personally


Level of consciousness

Consciousness


Lethargy


Sleepiness

Has a Glasgow Coma Scale of 10 (see Chapter 6)


Seems mentally slowed down


Dozes off repeatedly


Cognition


Orientation

Person


Place


Time

Does not know her name or with whom she lives


Does not know where she is


Does not know the year, day, or time


Memory

Immediate


Recent


Remote

Cannot remember three words when questioned after 5 minutes


Cannot remember her activities during the last 12 hours (verify information to rule out confabulation, that is, filling in memory gaps with false information)


Cannot remember where she was born


Attention and concentration

Attention


Concentration

Cannot pay attention to you without being distracted by other stimuli


Cannot repeat a string of three to six numbers forward and backward (digit span) or spell the word “world” backward


Cognitive ability

Verbal ability


Spatial ability


Abstraction ability

Cannot read a simple paragraph of text; cannot tell you how many states make up the United States


Cannot copy a simple drawing


Cannot describe how a pear and an apple are alike


Cannot explain the meaning of the proverb, “People who live in glass houses should not throw stones”


Speech

Timbre


Speed


Articulation


Deficiencies in language

Speaks too softly


Speech is pressured (seems compelled to speak quickly)


Speech is not readily understandable


Uses words poorly or has a poor vocabulary


Emotional state

Mood

Describes feeling depressed (low, hopeless, helpless, suicidal) or manic (high, euphoric, irritable)

Affect

Shows decreased (blunted, restricted, or flat) external expression of mood

Congruence

Described mood and visible affect are dissimilar

Appropriateness

Is laughing while telling a sad story


Thought and perception


Form or process (associations between thoughts)

Flight of ideas


Perseveration


Echolalia

Has thoughts that move rapidly from one to the other


Repeats thoughts over and over


Responds to the rhyming sounds rather than to the meaning of a word


Content

Compulsions


Obsessions


Phobias


Delusions


Idea of reference

Cannot refrain from performing an act (e.g., washing his hands)


Cannot get a thought out of his head (e.g., his hands have germs all over them)


Has irrational fears (e.g., is afraid to eat in a public place)


Has a false belief (e.g., is convinced that spies are after him)


Believes that things in the outside world refer to him (e.g., is sure that an actor in a movie is talking about him)


Perception

Illusions


Hallucinations


Depersonalization and derealization

Misinterprets reality (e.g., thinks that a toy on the floor in a dark room is a live pet)


Has false sensory perceptions (e.g., feels insects crawling on his skin when none exist)


Has a feeling of being outside of himself or the environment (e.g., believes he is watching himself in a play)


Judgment and insight


Judgment and insight

Judgment


Insight

Gives an unusual response to a hypothetical situation (e.g., says she would discard a stamped, addressed letter found on the sidewalk)


Does not realize that her thoughts and perceptions are not rational (e.g., says that she washes her hands excessively because they have “germs all over them”)


Reliability and impulse control

Truthfulness


Aggressive and sexual impulses

Provides incorrect information about previous hospitalizations (based on information from family or friends as well as clinical judgment)


Cannot control impulses (based on the history and current behavior)



Determinants of intelligence

Monozygotic twins tend to have equivalent intelligence even if they are raised in separate households. Approximately one-half of the difference between one person’s intelligence test score and the scores of unrelated others (the variance) can be explained by genetic factors (Bouchard et al., 1990; Weiss, 1992; Plomin et al., 1994). Biological factors that negatively affect intelligence include poor nutrition and illness early in life. Environmental factors (such as exposure to educational enrichment), social factors (such as a good parent-child relationship), and emotional factors (such as a positive response to a testing situation) can influence performance on intelligence tests.

Ethnic differences can affect performance on intelligence tests. Comparisons between the two largest ethnic groups suggest that white Americans tend to score higher than African Americans. Because intelligence tests use culture-specific language and tend to reflect the values and knowledge of American middle-class white culture, this difference in test performance has been attributed primarily to cultural and socioeconomic factors (Helms, 1992).

In the absence of brain pathology, intelligence is relatively stable throughout life. Although an individual’s intelligence is essentially the same in old age as in childhood, a characteristic decrease in processing speed with age can affect performance on timed aspects of standardized intelligence tests.

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Jun 16, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Psychological Assessment of Patients with Behavioral Symptoms

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